| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,273 |
3,257 |
$201K |
| D1120 |
Prophylaxis - child |
4,851 |
4,828 |
$188K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,954 |
882 |
$130K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,928 |
1,923 |
$127K |
| D0230 |
Intraoral - periapical each additional radiographic image |
24,557 |
4,684 |
$101K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,391 |
724 |
$79K |
| D1310 |
|
1,632 |
1,620 |
$72K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,895 |
4,870 |
$66K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,145 |
428 |
$62K |
| D9993 |
|
973 |
971 |
$61K |
| D2140 |
|
734 |
335 |
$40K |
| D1351 |
Sealant - per tooth |
1,489 |
428 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,560 |
1,557 |
$33K |
| D0350 |
|
2,930 |
1,346 |
$29K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
191 |
92 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
335 |
155 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,875 |
1,865 |
$22K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
215 |
110 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,525 |
1,495 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
239 |
239 |
$11K |
| D0603 |
|
691 |
689 |
$10K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
19 |
12 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
93 |
93 |
$5K |
| D1206 |
Topical application of fluoride varnish |
151 |
151 |
$5K |
| D0601 |
|
307 |
306 |
$4K |
| D1320 |
|
422 |
422 |
$4K |
| D2160 |
|
23 |
12 |
$2K |
| D2330 |
|
23 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$967.50 |
| D0602 |
|
64 |
64 |
$907.50 |